Case #5
A 37-year-old male visited his family dentist for a prophy. During the oral exam, a white plaque was noted on the dorsal tongue.
Joen Iannucci Haring, DDS, MS
History
When questioned about the lesion, the patient stated he was aware of the white patch on the tongue and that it had been present for approximately two weeks. The patient denied any pain or burning in the affected area, reporting that the lesion had not appeared to increase or decrease in size.
At the time of the dental appointment, the patient appeared to be in a general good state of health. He reported a recent use of antibiotics for an upper respiratory infection. No other health problems were noted, and no medications were being taken by the patient at the time of the dental examination. The patient`s dental history included regular examinations and routine dental treatment.
Examinations
The patient`s vital signs were all found to be within normal limits. Examination of the head and neck region revealed no palpable lymph nodes. No significant or unusual findings were discovered during the extraoral examination.
Intraoral examination revealed a white plaque on the midline of the posterior dorsal tongue measuring approximately 1.5 cm in diameter (see photo). The lesion could not be removed by wiping or scraping. Further oral examination revealed no other lesions present.
Clinical Diagnosis
Based on the clinical information available, which one of the following is the most likely diagnosis?
- vitamin deficiency
- benign migratory glossitis
- hyperplastic candidiasis
- allergic reaction
- lupus erythematosus
Diagnosis
hyperplastic candidiasis
Discussion
Candidiasis is the most common fungal infection of the oral cavity. Other synonyms for this disease include candidosis, a British term, and moniliasis, an outdated name derived from the archaic designation of the causative organism.
Oral candidiasis is caused by the yeast-like fungus, Candida albicans. The genus Candida includes eight species of fungi, of which Candida albicans is the most prevalent. Other members of the Candida genus may occur intraorally, but rarely cause disease.
Candida albicans may exist in one of two forms: in a yeast (spore) form, or, in a hyphal (filament) form. With clinical evidence of disease, the hyphal form is present and associated with the invasion of tissue. In contrast, the yeast form is innocuous and not seen in association with infection.
The Candida albicans organism is part of the normal oral micro flora. Approximately 30 to 50 percent of individuals carry this organism in their mouths without clinical evidence of infection. The presence of candidiasis depends on the immune status of the host and the oral mucosal environment.
It was previously believed that candidiasis was an opportunistic infection only affecting individuals debilitated by another disease process. It is now recognized that oral candidiasis may be seen in persons who are otherwise healthy.
Any one of the following factors listed may predispose a person to oral candidiasis: denture wearers, cigarette smokers, xerostomia, acidic saliva, antibiotic therapy, corticosteroid use, old age, immunosuppression, diabetes, HIV disease, radiation therapy, chemotherapy, blood dyscrasias, diet, infancy, and decreased vertical dimension.
Candida albicans can be described as a commensal organism that becomes pathogenic when predisposing factors exist.
Clinical Types
Clinically, there are four different types of candidiasis found in the oral cavity: hyperplastic, pseudomembranous, erythematous, and angular cheilitis. Each type has a different clinical appearance. Many patients present with a single type of candidiasis while others may exhibit more than one clinical form.
Hyperplastic candidiasis: The hyperplastic form (a.k.a. candidal leukoplakia) of candidiasis is the least common type of candidiasis. It can be described as a white plaque that cannot be removed by wiping or scraping.
Hyperplastic candidiasis is most often located on the anterior buccal mucosa close to the commissure area. Hyperplastic candidiasis may also be found on the lips and the tongue. No symptoms are associated with this form of candidiasis.
Pseudomembranous candidiasis: The pseudomembranous form of oral candidiasis is common. Also known as thrush, this form is the most widely recognized type of candidiasis. Pseudomembranous candidiasis may involve any portion of the oral cavity. Most frequently involved sites include the buccal mucosa, dorsal tongue, palate, gingiva and floor of the mouth. The entire oral cavity may be involved in severe cases.
This form of candidiasis may be seen at any age and there is no sex predilection. Infants and chronically ill patients are especially predisposed to pseudomembranous candidiasis.
Clinically, the pseudomembranous form of candidiasis is characterized by the presence of creamy, soft-white plaques resembling curdled milk. The plaques represent clumps of fungal hyphae interspersed with yeasts, desquamated epithelial cells, debris, and bacteria. These plaques can be easily removed by wiping or scraping.
The mucosa underlying these plaques may appear reddened or normal in color and should appear intact without erosion or ulceration. If an ulceration or erosion is noted, another lesion is present (e.g., erosive lichen planus). Symptoms associated with pseudomembranous candidiasis include an unpleasant taste or burning sensation.
Erythematous candidiasis: The erythematous form (a.k.a. atrophic candidiasis) of oral candidiasis is also common. As the term erythematous suggests, this form of candidiasis is typically seen in adults and there is no sex predilection. The typical presentation of erythematous candidiasis is that of a red patch; the red color may range from an obvious bright fiery red to a faint and subtle red.
When located on the dorsal tongue, the lesion is associated with the loss of filiform papillae. Due to this lack of papillae, erythematous candidiasis appears as a "bald" spot on the tongue. The terms median rhomboid glossitis and central papillary atrophy have been used to describe this presentation of candidiasis.
Erythematous candidiasis is typically seen in denture wearers and may be described as either asymptomatic or painful. In asymptomatic cases, the lesion is typically discovered upon routine oral examination. It is important to note that erythematous candidiasis may often be overlooked when it appears as a faint red patch.
Angular cheilitis: Angular cheilitis, or perlèche, is also a form of candidiasis. This form of candidiasis is often mistakenly identified as a vitamin deficiency. Angular cheilitis is often seen in conjunction with Staphylococcus aureus. Studies have indicated that 20 percent of all cases are caused by Candida albicans alone, 60 percent are caused by a combination of Staphylococcus aureus and Candida albicans, and 20 percent are caused by Staphylococcus aureus alone.
Angular cheilitis may be seen in any age group and is characterized by an erythematous, fissured area in the corner of the mouth. This tissue in the commissure region appears wrinkled and macerated. A superficial crust may be seen superimposed over the affected area. Angular cheilitis may involve one commissure or both. Pronounced folds of skin in the commissure region or decreased vertical dimension may act as a predisposing factor for angular cheilitis. Accentuated folds in the corner of the mouth region of older individuals often provide a suitable environment for the growth of Candida albicans.
Angular cheilitis only involves the commissure portion of the lip and adjacent skin. It does not cross the mucosal surface and involve the tissues within the oral cavity.
Symptoms of angular cheilitis include a dryness, tightness, or burning sensation in the commissure region. Without treatment, the lesion tends to persist, and in some cases, last for months. Spontaneous regression may be seen; in which case, a recurrence is not uncommon. Angular cheilitis is often seen in conjunction with one of the other three types of oral candidiasis. Consequently, any patient with angular cheilitis should be carefully examined for intraoral evidence of disease.
Diagnosis
The differential diagnosis for oral candidiasis includes a number of lesions. A complete patient history, particularly the history of antibiotic and corticosteroid use, aids the dental professional in limiting the differential diagnosis. Lesions such as leukoplakias, genokeratoses, lichen planus, allergic reactions, chemical trauma, and thermal trauma may all be considered in the differential diagnosis. Instances of candidiasis without an identifiable cause arouse suspicion concerning an underlying problem with the immune system.
Although the clinical presentation of candidiasis is highly suggestive, a laboratory confirmation of the diagnosis is preferred. All forms of oral candidiasis can be diagnosed using cytologic examination and culture techniques. In the dental setting, the diagnosis is usually based on the clinical appearance in conjunction with exfoliative cytologic examination.
Treatment
Antifungal drugs are used to treat all types of candidiasis. Topical or systemic antifungal drugs may be used. When prescribing such medications, a number of factors should be taken
into consideration: medical history, patient compliance, disease severity and the presence of partial or complete dentures.
Post-treatment evaluation of a patient with candidiasis is prudent. If no improvement is noted after 10 to 14 days of treatment, the patient must be re-evaluated. Patients without predisposing factors should be referred to a physician for evaluation.
Candidiasis and the dental patient
Candidiasis is a common oral condition that should not be ignored by the dental professional. Candidiasis may indicate a variety of serious underlying and undiagnosed systemic problems. If the underlying cause for the candidiasis cannot be identified, or if a patient fails to respond to treatment, it is critical that a referral to a physician be made.
Because candidiasis is often seen in immunocompromised patients, it is important to note that candidiasis may be the first indication of HIV disease. Candidiasis is not a contagious disease. There is no risk involved for the dental professional in treating a patient with candidiasis.
Candidiasis can be successfully treated by the dentist using antifungal medications and managed with careful periodic re-evaluations.
Joen Iannucci Haring, DDS, MS, is an associate professor of clinical dentistry, Section of Primary Care, The Ohio State University College of Dentistry.
